How should beta blockers be managed in the perioperative (around the time of surgery) setting?

Beta-Blocker Management in the Perioperative Setting

Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically for treatment of conditions with ACCF/AHA Class I guideline indications. 1

Continuing Beta-Blockers in the Perioperative Period

• Beta blockers should be continued in patients who are receiving them chronically for conditions such as angina, symptomatic arrhythmias, hypertension, or other guideline-indicated conditions 1
• Abrupt discontinuation of beta blockers in patients with coronary artery disease can lead to severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 2, 3, 4
• Multiple observational studies support the benefits of continuing beta blockers in patients who are undergoing surgery and who are on these agents for longitudinal indications 1

Management of Beta-Blockers After Surgery

• It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started 1
• Particular attention should be paid to the need to modify or temporarily discontinue beta blockers as clinical circumstances (e.g., hypotension, bradycardia, bleeding) dictate 1
• If beta blockers are to be continued perioperatively, patients should be monitored closely when anesthetic agents which depress myocardial function are used 2

Initiating Beta-Blockers in the Perioperative Period

For patients not already on beta blockers, the following recommendations apply:

• In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers 1
• In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, heart failure, coronary artery disease, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery 1
• If beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery 1
• Beta-blocker therapy should not be started on the day of surgery due to increased risk of harm 1

Risk Stratification for Beta-Blocker Use

• The relationship between perioperative beta-blocker treatment and the risk of death varies directly with cardiac risk 5
• Among patients with an RCRI score of 0 or 1, beta-blocker treatment may be associated with no benefit and possible harm 5
• For patients with RCRI scores of 2,3, or 4 or more, beta-blockers are associated with reduced risk of in-hospital death 5

Beta-Blocker Selection and Administration

• When beta blockers are used perioperatively, they should be titrated to heart rate and blood pressure 1
• No significant differences in perioperative risks have been found between common beta-blocker subtypes (metoprolol, atenolol, carvedilol) in general populations 6
• However, in patients with prior myocardial infarction, carvedilol may be associated with lower all-cause mortality compared to metoprolol 6

Common Pitfalls and Caveats

• Abrupt withdrawal of beta-blockers can precipitate adverse cardiac events; if withdrawal is necessary, taper therapy over approximately one week 2, 3, 4
• Beta-blockers may mask signs of hypoglycemia, particularly tachycardia, which is important to consider in diabetic patients 2, 3, 4
• Beta-blockers may mask clinical signs of hyperthyroidism and abrupt withdrawal may precipitate thyroid storm 2, 3, 4
• Patient understanding of the importance of perioperative beta-blockade is often poor, with only 49% of patients on chronic beta-blockers recognizing their perioperative benefit 7
• The impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia if beta-blockers are continued 2, 3, 4